Chronic subdural hematoma (cSDH) is a common cranial neurosurgical conditionwith morbidity and mortality ranging from 2% to 5%. Conventional treatmentincludes conservative and surgical evacuation. Minimally invasive middlemeningeal artery (MMA) embolisation is emerging as a potential treatmentoption. We report our case successfully managed by MMA embolization andreview the literature. cSDH development and progression is related to the cycleof chronic inflammation and angiogenesis following the original hemorrhagedue to trivial trauma. Due to growth factor, stimulation‑initiating angiogenesisleading to growth of leaky blood vessels causing microhaemorrhages resulting inthe progressive enlargement of subdural collection as the physiologic absorptioncapability is outpaced by the rate of collection. Strategies for the management ofcSDH are aimed at interrupting the vicious cycle of its development and tilting thebalance toward reabsorption of haemorrhage. Conservative management, medicaltreatment and surgical treatments are conventional treatment options with surgicalevacuation considered as the gold standard option. However, challenges includerecurrence and reversal of anti‑platelets and anti‑coagulants and its associated riskof ischaemic complications. cSDH being a pathology of meninges deriving bloodthe dura causing microhaemorrhages, it is prudent to seal off the vessels to tiltthe balance towards resorption. MMA embolisation as a treatment option has beenused with significant published data. It may be used as a stand‑alone therapy inminimally symptomatic patients. Technical success rate is high both with polyvinyalcohol and liquid embolic agents. Recurrence rate is consistently low in spite ofsignificant patients having antiplatelets and anti‑coagulants on board. It eliminatesthe ischemic complication due to stoppage of antiplatelets and anticoagulants.MMA embolization is also emerging as an adjunct to surgically evacuated cSDHthat is considered high risk for recurrence.Keywords: Burr hole evacuation, chronic subdural hematoma, craniotomy,middle meningeal artery embolisation, polyvinyl alcohol embolisationMiddle Meningeal Artery Embolization in the Management of ChronicSubdural Haematoma: A Case Report and Review of LiteratureSrinivasan Paramasivam, Harihara SudanAccess this article onlineQuick Response Code:Website: www.jcvs.inDOI: 10.4103/jcvs.jcvs_7_20Address for correspondence: Dr. Srinivasan Paramasivam,E-mail: neurosurgeonsrini@gmail.comfrom 2% to 5%,[2] but 6 month and 1 year mortality afterthe diagnosis of cSDH is estimated to be about 30%making this a sentinel health event marking a reducedlife span compared to matched controls.[3,4] Studies onthe outcomes of cSDH have branded this a disablingReview ArticleIntroductionChronic subdural hematoma (cSDH) is slow andprogressive collection of blood in the subdural spacecommonly diagnosed in old age following trivial trauma.Its ever‑increasing frequency is attributed to increasedlife expectancy and more frequent use of anti‑coagulantsand anti‑platelet medications. It is expected to be themost common cranial neurosurgical condition in 2030among adults.[1] Morbidity and mortality are low rangingDepartment of Neurosurgery,Apollo Hospitals, Chennai,Tamil Nadu, IndiaAbstractThis is an open access journal, and articles are distributed under the terms of the CreativeCommons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others toremix, tweak, and build upon the work non‑commercially, as long as appropriate credit isgiven and the new creations are licensed under the identical terms.For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.comHow to cite this article: Paramasivam S, Sudan H. Middle meningeal arteryembolization in the management of chronic subdural haematoma: A casereport and review of literature. J Cerebrovasc Sci 2020;8:45-9.Submitted: 10-Aug-2020Accepted: 01-Sep-2020Published: 01-Oct-2020[Downloaded free from http://www.jcvs.in on Monday, January 17, 2022, IP: 10.232.74.27]Paramasivam and Sudan: Middle meningeal artery embolization in the management of chronic subdural haematoma46 Journal of Cerebrovascular Sciences ¦ Volume 8 | Issue 1 | January-June 2020and not a benign problem with increased mortality forup to 1 year after diagnosis.[5] Headache is the commonsymptoms of cSDH, followed by weakness, balance,gait disturbances, and cognitive decline.[6] Conventionaltreatment includes conservative management and surgicalevacuation. cSDH being a disorder of blood vessels ofthe meninges, minimally invasive neuroendovascularmanagement is a potential treatment option.Case ReportA 57‑year old male without a significant past historyhad a trivial head trauma due to road traffic accident.The event was not significantly eventful, managedconservatively, reassured and he continued to do hisroutine. Three weeks later developed progressive,persistent right sided headache. He was evaluatedwith computed tomography (CT) scan brain plainthat revealed right frontotemporoparietal hypodensecollection with areas of hyperdensity and tentorialhyperdensity [Figure 1]. A diagnosis of cSDH wasmade. In view of mild but progressive symptoms,we treated him by super selective catheterisation andendovascular embolization of right middle meningealartery (MMA) branches using polyvinyl alcohol (PVA)particles under conscious sedation [Figure 2a and b].Immediately following the procedure, he had relief ofheadache. He was discharged the following day. Heresumed normal activities few days later. Follow‑upevaluation at 1 month, he continued to be asymptomaticand CT scan brain revealed complete resolution of thecSDH [Figure 2c‑f].Development and progression of chronicsubdural hematomacSDH development and progression are related to cycleof chronic inflammation and angiogenesis. Following theoriginal haemorrhage due to trivial trauma, organisationof clot, fibrinolysis and liquefaction of clot ensues. Theserous fluid intermixed with clotted blood, relies onneuroparenchymal counter pressure for resorption. Thereorganisation and formation of vascular membranesthat encapsulate the cSDH can prevent reabsorption. Theclot breakdown products stimulate inflammation withthe increased levels of interleukin‑6, vascular endothelialgrowth factor and fibroblast growth factor leadingto thickening of inner dural border cells initiatingangiogenesis with ingrowth of immature capillarieswhich leak blood leading to microhaemorrhages. Thesemicrohaemorrhages lead to slow and progressiveenlargement of subdural collection along with increasedfibrinolysis, inflammation, membrane formation,angiogenesis and vascular proliferation cycle overand over again leading to sizable collection causingmass effect and clinical symptoms as the physiologicabsorption capability is outpaced by the rate ofcollection.[6‑8]Conventional treatment optionsStrategies for the management of cSDH are aimed atinterrupting the vicious cycle of its development andtilting the balance towards reabsorption of haemorrhage.Therapy involves irrigation and removal of bloodproducts resulting in changing the osmotic environmentalong with reducing the microhaemorrhages by alteringangiogenesis. The procedure varies widely betweenindividual physician and institutions with no guidelinesfor the management.Conservative management is considered in patients withminor symptoms, small cSDH measuring <10 mm withminimal or no mass effect. Spontaneous resolution ofsymptomatic cSDH is relatively unusual and may beexpected in a small cSDH that is asymptomatic.[9,10]Medical treatment with steroids, platelet‑activating factorantagonists and statins have been proposed with highfailure rate requiring surgical bailout.[11‑13] However,they need to be followed closely for the progressionof symptom and sudden deterioration. This strategyrequires prolonged hospitalisation, reduced activity andnumerous serial imaging along with discontinuation ofanti‑platelets and anti‑coagulants for prolonged period.Surgical management include twist drill hole or burrhole evacuation and craniotomy and evacuation thatmay range from minicraniotomy to large craniotomywith or without excision of the membrane. Smallcomparative studies exist between various surgicaltechniques with each other, but no comprehensive studyto compare surgery versus conservative managementexists. Outcomes of treatment in general are favourable,but the major challenges are recurrence of cSDH thatis reported to vary between 2% and 37% with mostseries reporting between 10% and 20%[5,14‑16] In ameta‑analysis, recurrence or reoperation rate was 11.7%for burr hole evacuation, 19.4% for craniotomy, and28.1% for twist drill craniostomy. Other challengesbeing reversal of anti‑platelets and anti‑coagulants andits associated risk of ischaemic complications. Overall,it is a disease of old age patients having comorbiditiesadds morbidity to cranial surgery,[17] and less invasiveoptions are preferable for selected patients.[18]Middle meningeal artery embolisation as acure for chronic subdural hematomacSDH being a pathology of meninges deriving bloodfrom the blood vessels of the dura and causingmicrohaemorrhages form the immature vessels formedform angiogenesis, it is prudent to seal off the vessels[Downloaded free from http://www.jcvs.in on Monday, January 17, 2022, IP: 10.232.74.27]Paramasivam and Sudan: Middle meningeal artery embolization in the management of chronic subdural haematomaJournal of Cerebrovascular Sciences ¦ Volume 8 | Issue 1 | January-June 2020 47Figure 1: CT scan Brain in patient with trivial trauma 3 weeks ago and now presenting with headache. The scan shows right fronto temporopareitalsubdural hematoma with mass effectdhcgbfaeFigure 2: (a-b) Superselective catheterisation of the right middle meningeal artery showing diffuse enhancement of the subdural membrane (Arrowhead in A). The lacrimal branch of middle meningeal vessel that anastomoses with ophthalmic artery, that needs to be preserved is shown in A andB (Asterisk). Following PVA embolization, the stump of middle meningeal artery is visualised (Arrow in B). (c-f) Follow up CT scan Brain at onemonth post procedure reveals complete resolution of the hematoma and the mass effectc dbfae[Downloaded free from http://www.jcvs.in on Monday, January 17, 2022, IP: 10.232.74.27]Paramasivam and Sudan: Middle meningeal artery embolization in the management of chronic subdural haematoma48 Journal of Cerebrovascular Sciences ¦ Volume 8 | Issue 1 | January-June 2020to tilt the balance towards absorption without furtherhemorrhage resulting in the resolution of the hematoma.MMA embolization as a sole therapy or as an adjunctto surgical evacuation has been used and variousseries have published the data. As early as 2000,Mandai et al. have published successful treatment of arefractory cSDH with MMA embolisation in a patientwith coagulopathy due to liver cirrhosis.[19] Ban et al.have reported a detailed evaluation and in their seriesof 72 consecutive cases, 27 cases were primarilyembolised and 45 were embolised prior to surgicalevacuation. They compared their results with 439historical controls treated conventionally. Treatmentfailure was defined as either requiring rescue surgeryin conservative group, reoperation in surgical group orincomplete resolution or re‑accumulation or more than10 mm at 6 months follow‑up CT scan. Compared withthe same institution data, there was 83.6% failure ratein the conservative group and 18.2% in the surgicalgroup. Comparative results favour embolisationwith a success rate of 98.6% as against 72.5% in thecontrol arm (P < 0.001).[18] Comparison of surgicalretreatment versus endovascular embolisation inrecurrent cSDH reported by El Kim et al. has shownhigher rate of hematoma cure with shortened brainre‑expansion time in embolisation group compared toconventional treatment. The recollection rate after thesecond procedure was 3.8% vs 33.3% in favour ofembolisation group.[20]Patients selected for embolisation were on antiplateletor anticoagulant medications, and they were treated withembolisation without the need to stop the medications.Meta‑analysis of nine case series has shown therecurrence rate after embolization to be as low as 2.1%as against 27.7% with conventional treatment (oddsratio [OR] = 087, 95% confidence interval [CI]0.026–0.292, P < 0.001). Procedural complicationrates were similar between the two groups 2.1% vs.4.4%; OR = 0.563; 95% CI, 0.107–2.96; P = 0.497.[21]Subsequently, published three case series did not haveany recurrence in the embolised patients.[1]MMA embolisation can be done with either PVAparticles or using liquid embolic agents. In most cases,embolisation using PVA particles of size 150–250 µ ispossible and distal penetration can be achieved withgood results and it is relatively cheap. The microcatheterin most situations is as large as the MMA and so onlysmall amount of particles can be injected. However, ifthe microcatheter is wedged, liquid embolic material canbe injected effectively having good distal penetrationwith casting of membrane along with back filling ofadjacent vessels.[3] Unlike the PVA particles mixedwith contrast, the liquid embolics are uniformly mixedwith tantalum powder making the visibility better asit penetrates distal branches and it causes permanentocclusion of the vessel. Currently, most series reportedare reported with PVA particles used as embolisationagent, and most cases are done under conscious sedation.MMA embolisation as a treatment options for cSDHis promising with currently available literature. This isprimarily chosen as a treatment option for minimallysymptomatic cSDH with mass effect without motordeficit and radiologic progression of hematoma. Theadvantages are, it is minimally invasive, targets theroot cause of the disease, performed under conscioussedation, in surgically high‑risk groups such as thoseon anti‑platelets, anti‑coagulation without the needto stop it, those with thrombocytopenia and otherco‑morbidities. It is also used as an adjunct to surgeryin patients with significant mass effect and motor deficitand has a higher risk of recurrence following surgery.ConclusionChronic subdural hematoma has various treatmentoptions based on presentation and institutionalpreference. In addition to the conventional treatmentoptions, MMA embolization has emerged as apotential alternate stand‑alone treatment and adjunct toconventional treatment with high success rate and lowrecurrence rate.Declaration of patient consentThe authors certify that they have obtained allappropriate patient consent forms. In the form thepatient(s) has/have given his/her/their consent for his/her/their images and other clinical information to bereported in the journal. The patients understand that theirnames and initials will not be published and due effortswill be made to conceal their identity, but anonymitycannot be guaranteed.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest.References1. Srivatsan A, Srinivasan VM, Thomas A, Burkhardt JK,Johnson JN, Kan P. Perspective on safety and effectiveness ofmiddle meningeal artery embolization for chronic subduralhematoma. World Neurosurg 2019;127:97‑8.2. Ramachandran R, Hegde T. Chronic subdural hematomas‑causesof morbidity and mortality. Surg Neurol 2007;67:367‑72.3. Fiorella D, Arthur AS. Middle meningeal artery embolization forthe management of chronic subdural hematoma. J NeurointervSurg 2019;11:912‑5.[Downloaded free from http://www.jcvs.in on Monday, January 17, 2022, IP: 10.232.74.27]Paramasivam and Sudan: Middle meningeal artery embolization in the management of chronic subdural haematomaJournal of Cerebrovascular Sciences ¦ Volume 8 | Issue 1 | January-June 2020 494. Dumont TM, Rughani AI, Goeckes T, Tranmer BI. Chronicsubdural hematoma: A sentinel health event. World Neurosurg2013;80:889‑92.5. Miranda LB, Braxton E, Hobbs J, Quigley MR. Chronic subduralhematoma in the elderly: Not a benign disease: Clinical article.J Neurosurg 2011;114:72‑6.6. Sahyouni R, Goshtasbi K, Mahmoodi A, Tran DK, Chen JW.Chronic subdural hematoma: A historical and clinical perspective.World Neurosurg 2017;108:948‑53.7. Ito H, Yamamoto S, Komai T, Mizukoshi H. Role of localhyperfibrinolysis in the etiology of chronic subdural hematoma.J Neurosurg 1976;45:26‑31.8. Edlmann E, Giorgi‑Coll S, Whitfield PC, Carpenter KLH,Hutchinson PJ. 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